Clerking haemoptysis

Haemoptysis may be defined as a small amount of blood-streaked sputum to massive bleeding with life-threatening consequences due to airway obstruction and haemodynamic instability. In clerking haemoptysis, the following clinical definitions may be used to characterise the severity:

  • Mild haemoptysis: <15 mL to 30 mL over 24 hours
  • Frank haemoptysis: >15 to 30 mL and <600 mL over 24 hours
  • Massive haemoptysis: 600 mL or more over 24 hours.

Greater than 150 mL haemoptysis may be considered life-threatening, as this volume of blood could flood the conducting airways completely.

It is essential to differentiate between haematemesis (the vomiting of blood), pseudohaemoptysis (the coughing of blood from a source other than the lower respiratory tract), and haemoptysis; identify the site of bleeding; and narrow the differential diagnosis. 

History

Greet the patient and establish rapport.

Obtain the biodata, noting the age and occupation.

Explore the various possible aetiologies in the body of the history as follows:

  • Acute/chronic bronchitis: 

frequent cough with excessive mucus production; chest pressure or pain; triggers include tobacco smoke, cannabis, ammonia, trace metals (vanadium, cadmium), air pollutants, and various infectious agents

  • Pulmonary tuberculosis:

hx of travel to endemic areas, exposure to people with tuberculosis, risk factors for HIV, unstable living environment (e.g., homelessness); cough, dyspnoea, weight loss, fever, joint aches, drenching night sweats

  • Lung abscess:

high fever (>38.5°C [>101°F]), productive cough, purulent sputum, weight loss, malaise, fever, night sweats; massive haemoptysis may occur with chronic abscesses

  • Pneumonia:

tobacco use, fever, cough, dyspnoea, chest pain

  • Primary lung cancer:

new cough, dyspnoea (worse at night or in recumbent position), chest pain, weight loss, occurrence of para-neoplastic syndrome

  • Lung metastasis:

symptoms related to the primary neoplastic site, pain, weight loss, malaise, cough, dyspnoea

  • Anticoagulants, thrombolytic agents:

exposure to anticoagulants, aspirin, thrombolytic agents

  • Toxic inhalation:

exposure to smoke inhalation, solvents, trimellitic anhydride

  • Bronchiectasis:

frequent cough with excessive mucus production and little seasonal variation, dyspnoea, pleurisy, fatigue, weight loss; hx of cystic fibrosis, alpha-1 antitrypsin deficiency, or other underlying chronic lung disease

  • Pulmonary thromboembolism:

dyspnoea, pleuritic chest pain, cough, syncope

  • Mitral valve stenosis:

chronic dyspnoea, dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations; may become clinically apparent with pregnancy-induced haemodynamic changes; hx of recurrent respiratory infections (group A haemolytic streptococci) during childhood, rheumatic fever, rheumatic heart disease, living in endemic areas for mitral stenosis, atherosclerotic heart disease, and/or mitral annular calcification

  • Left ventricular failure: 

hx of hypertension, diabetes mellitus, dyslipidaemia, tobacco use, or coronary, valvular, or peripheral vascular disease; dyspnoea, palpitations, chest discomfort, night cough, fatigue, muscle weakness, or tiredness

  • Coagulopathy:

association with liver disease, end-stage renal failure, or specific disorders of coagulation cascade (factor deficiency); menorrhagia

  • Thrombocytopenia:

usually incidental; may present with purpura or be associated with gestation, HIV, liver disease, myelodysplastic syndrome, or drug-induced; menorrhagia

  • Disseminated intravascular coagulation:

fever, cough, dyspnoea, confusion, epistaxis, bleeding gums; possible history of sepsis, obstetric complications such as abruptio placentae, snake bite, malignancy (e.g., acute promyelocytic leukaemia), or tissue trauma (e.g., surgery)

  • Aspergilloma:

mostly asymptomatic, commonly secondary to tuberculosis; weight loss, chronic cough, malaise

  • Endobronchial carcinoid:

asymptomatic; may cause cough, dyspnoea, wheezing if nodule is endobronchial

  • Aspiration of foreign body:

may be asymptomatic, inspiratory stridor, cough paroxysms, localised wheezing, choking crisis; most common in children <15 years of age; associated with alcohol abuse, sedative use, poor dentition, neurological disease, loss of consciousness, seizure in older adults

  • Aspiration of gastric contents:

hx of GORD, age >70 years, male sex, general anaesthesia, cerebrovascular disease; fever, intractable cough, dyspnoea

  • Broncholithiasis: 

chronic cough, occasional chest pain, may be asymptomatic, hx of recurrent pneumonias in same location

  • Tracheo-oesophageal fistula:

feeding difficulties or respiratory distress in newborns

  • Bronchial telangiectasia:

sometimes associated with hereditary haemorrhagic telangiectasia, recurrent epistaxis

  • Airway trauma: 

recent hx of high-velocity accident, blunt trauma to neck or chest, or exposure to explosive blast; iatrogenic haemoptysis may occur with traumatic intubation, bronchoscopy, and endobronchial therapeutic manoeuvres

  • Dieulafoy’s disease:

congenital origin; hx of co-morbidities: cardiovascular disease, hypertension, chronic renal failure, diabetes, or alcohol abuse

  • Thoracic endometriosis:

catamenial symptoms (within 24-48 hours of onset of menstruation); may have dysmenorrhoea, dyspareunia; chest pain, shortness of breath

  • Pulmonary artery aneurysm:

congenital or related to pulmonary artery catheter complication

  • Fat embolism:

dyspnoea, fever, changes in mental status; usually 24 to 72 hours after long-bone fracture or liposuction

  • Tumour embolism:

hx of mucin-secreting adenocarcinomas (breast, lung, stomach, colon), hepatoma, prostate cancer, choriocarcinoma, or renal cell carcinoma

  • Arteriovenous malformation:

dyspnoea is uncommon

  • Pulmonary haemorrhagic syndromes:

cough, fever, dyspnoea; hx of bone marrow transplant; hx of connective tissue disease or vasculitis

  • Granulomatosis with polyangiitis (formerly Wegener’s granulomatosis):

cough, chest pain, dyspnoea, rhinorrhoea, epistaxis, ear/sinus pain, hoarseness, fever, fatigue, anorexia, weight loss

  • Systemic vasculitis:

complaints of arthralgias, myalgias, malaise, fatigue for several months before more specific signs or symptoms develop

  • Congenital heart disease:

from asymptomatic to disabling symptoms: progressive heart disease, dyspnoea, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea

  • Tricuspid endocarditis: 

hx of IV drug use, mitral valve prolapse, or congenital heart disease; fever, malaise, fatigue, chest pains, weakness, night sweats, palpitations

  • Bronchogenic cyst:

usually asymptomatic unless infected; incidental finding

  • Factitious haemoptysis:

frequently young patients, healthcare workers; evidence of self-inflicted wounds or interventions capable of causing haemoptysis supports the diagnosis

Past medical history may reveal a recent hospital admission and consequent immobility causing deep venous thrombosis and pulmonary embolism.

Social history may find long-term smoking to be a key factor in the condition. 

Drug history may show the use of anticoagulation therapy may indicate a coagulopathy.

Physical Examination

Physical findings are uncommon but may help to establish the cause of haemoptysis.

General examination

  • Look for signs such as a cachexia syndrome (weight loss and muscle wasting) which may indicate a primary lung cancer or metastases to the lungs.
  • Check for fever and note the temperature if abnormal. Fever may be a sign of multiple aetiologies including infectious, malignant, and inflammatory conditions.
  • Assess for pallor which may indicate malignancy.
  • Cyanosis and digital clubbing may point to non-small-cell bronchogenic carcinoma, bronchiectasis, and chronic lung abscess.
  • Lymphadenopathy may indicate malignancy, especially if mass lesions are present and the patient has risk factors for cancer. It may also indicate an infection.
  • The presence of ecchymoses and/or petechiae suggests haematological diseases.

Specific findings in each likely aetiology may be looked out for as follows:

  • Acute/chronic bronchitis: 

may be normal, cough with variable degrees of haemoptysis, normal to mildly elevated temperature, harsh breath sounds, rhonchi, expiratory wheezing

  • Pulmonary tuberculosis:

cachexia, fever, lymphadenopathy, rales, consolidation

  • Lung abscess:

fever, cardiac murmur, signs of gingival disease, cachexia, halitosis, amphoric or cavernous breath sounds, inspiratory crackles and/or bronchial breathing, decreased breath sounds; nail clubbing may occur with chronic abscesses

  • Pneumonia:

dullness to percussion, fever, unilateral rales

  • Primary lung cancer:

clubbing, focal wheezing

  • Lung metastasis:

clubbing, focal wheezing; physical findings may not be present

  • Anticoagulants, thrombolytic agents:

may be normal

  • Toxic inhalation:

may be normal, cough with variable degrees of haemoptysis

  • Bronchiectasis:

cough almost always present, with variable degrees of haemoptysis, crackles present in >70% of cases, wheezing in 34% of cases, clubbing in 3% of cases

  • Pulmonary thromboembolism:

usually non-revealing, unilateral lower-extremity oedema, split S2 with loud P2, diaphoresis, pleural rub, tachypnoea

  • Mitral valve stenosis:

reduced pulse pressure, elevated jugular venous distension, plethoric cheeks, right ventricular lift, atrial fibrillation, diastolic rumble, opening snap, loud S1, loud P2, hoarseness (recurrent laryngeal nerve impingement by the left atrium)

  • Left ventricular failure: 

neck vein distension, hepatojugular reflux, rales, S3 gallop, cardiomegaly, tachycardia (HR >120 bpm)

  • Coagulopathy:

petechiae, small capillary haemorrhages, ecchymoses, haematomas, haemarthrosis

  • Thrombocytopenia:

rarely purpura, mucosal bleeding, epistaxis, signs of liver disease

  • Disseminated intravascular coagulation:

petechiae, GI or GU tract bleeding, hypotension, tachycardia, pleural friction rub

  • Aspergilloma:

fever is rare, severe haemoptysis may occur

  • Endobronchial carcinoid:

often normal examination, unilateral wheezing may be present

  • Aspiration of foreign body:

focal wheezing, choking crisis, focal decrease in breath sounds

  • Aspiration of gastric contents:

fever, crackles, wheezing

  • Broncholithiasis: 

rarely wheezing due to airway obstruction

  • Tracheo-oesophageal fistula:

asymptomatic, laboured breathing, coughing, choking, cyanosis

  • Bronchial telangiectasia:

mucocutaneous telangiectasia, pulmonary bruit, stigmata of right-to-left shunting such as cyanosis and clubbing

  • Airway trauma: 

tachypnoea, wheezing, chest or neck pain; external signs may or may not indicate magnitude of trauma

  • Dieulafoy’s disease:

no physical findings: Dieulafoy’s disease is a vascular anomaly characterised by the presence of a tortuous dysplastic artery in the submucosa; most cases involve the gastrointestinal tract

  • Thoracic endometriosis:

no physical findings; pelvic tenderness, cul-de-sac nodularity may be present

  • Pulmonary artery aneurysm:

non-specific; chest pain may be present

  • Fat embolism:

hypoxaemia, tachypnoea, changes in mental status; petechiae in the head, neck, anterior chest, and axillae

  • Tumour embolism:

tachypnoea, hypoxaemia, tachycardia

  • Arteriovenous malformation:

pulmonary bruit; arteriovenous communications or haemorrhagic telangiectasia in skin, mucous membranes, and other organs; cyanosis, clubbing; neurological signs from cerebral aneurysms, cerebral emboli, or metastatic abscess

  • Pulmonary haemorrhagic syndromes:

usually negative; presence of leukocytoclastic vasculitis, arthritis, or synovitis, indicative of connective tissue disease

  • Granulomatosis with polyangiitis (formerly Wegener’s granulomatosis):

palpable purpura, painful ulcers, uveitis, wheezing, sinus tenderness

  • Systemic vasculitis:

specific organ involvement, which may demonstrate a pattern of disease (e.g., granulomatosis with polyangiitis [Wegener’s granulomatosis] is associated with chronic sinusitis; Churg-Strauss’s syndrome is associated with refractory asthma)

  • Congenital heart disease:

frothy pink sputum, stigmata of right-to-left shunting (cyanosis, clubbing), heart murmur, pectus excavatum

  • Tricuspid endocarditis: 

fever, Janeway lesions, Osler’s nodes, splinter haemorrhages, cardiac murmur

  • Bronchogenic cyst:

non-specific

  • Factitious haemoptysis:

absence of an alternative aetiology on work-up